Category: Disorders

The NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is a long-term outpatient study designed to find out which treatments, or combinations of treatments, are most effective for treating episodes of depression and mania and for preventing recurrent episodes in people with bipolar disorder.

1. Q. What was the goal of the STEP-BD depression psychosocial treatment trial and how did it fit into STEP-BD?

The study reported in the April 2007 issue of the Archives of General Psychiatry describes the results of a clinical trial examining the effectiveness of four psychosocial interventions for people with bipolar disorder who are experiencing a depressive episode. The clinical trial was part of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) research program, the largest, federally funded treatment trial ever conducted for bipolar disorder. STEP-BD enabled researchers to explore a range of treatment options related to bipolar disorder, including mood-stabilizing medications, antidepressants, atypical antipsychotic medications, and psychosocial interventions (talk therapies).

Once enrolled in the STEP-BD program, participants aged 15 or older received individualized care from their STEP-BD treatment provider that included the best available treatment options. This approach was called the Best Practice Pathway. Participants in the Best Practice Pathway who were age 18 or older and whose depression did not improve or who experienced a new depressive episode, could enter the randomized clinical trial that examined the effectiveness of different combinations of medication and psychosocial therapy for the depressive phase of bipolar disorder.

In this one-year randomized clinical trial, the goal of the psychosocial study was to determine if receiving intensive (and long-term) treatment with any one of the three psychosocial therapies offered in STEP-BD was more effective in relieving bipolar depression than receiving treatment with a brief, short-term talk therapy intervention.

2. Q. Why is the psychosocial treatment trial important?

Although various treatments currently are available for treating bipolar disorder, including medications and talk therapies, it is not known if psychosocial interventions, when received alongside medication, can help relieve bipolar-related depression and keep patients well in typical, real-world clinical settings. In addition, most previous clinical trials were conducted in single academic centers and included carefully selected groups of research participants who may be different from the people seeking care in everyday practice settings.

In this regard, the psychosocial treatment study in STEP-BD is unique because it included “real world” patients experiencing the early phases of a depressive episode, who were already receiving care for their bipolar disorder as part of STEP-BD. The therapists who delivered care in the psychosocial treatment study received STEP-BD training in the different psychosocial therapies by experts in the field. The training and ongoing supervision was of low intensity, consistent with what is typically available in clinical practice.

3. Q. How were participants selected for inclusion in the psychosocial treatment trial?

While enrolled in the STEP-BD Best Practice Pathway, participants were evaluated for depression at every follow-up visit. These clinic visits recorded and tracked participants’ treatment and assessed their symptoms and clinical status for the duration of participation in the study. If the study participants experienced a depressive episode, they could choose to leave the Best Practice Pathway and enter the randomized portion of STEP-BD; 366 participants did so.

The randomized acute depression study lasted 26 weeks and addressed the question of whether adding an antidepressant medication (buproprion or paroxetine) to an existing mood stabilizing medication is more effective for treating acute bipolar-related depression than adding a placebo pill. All participants in this portion were required to be on a mood stabilizing medication, such as lithium, valproate, carbamazepine or other mood stabilizer approved by the U.S. Food and Drug Administration.

These 366 participants also had the option of participating in the randomized psychosocial treatment study in which they would receive psychosocial treatment in addition to their medication treatment. Of the 366 participants who entered the randomized depression trial, 236 chose to enter the psychosocial portion. In addition, 57 STEP-BD participants who were enrolled in the Best Practice Pathway, but who were not part of the medication portion of the randomized depression trial, chose to enter the psychosocial study as well. Altogether, 293 participants took part in the psychosocial treatment study. Many of those who chose not to participate in the psychosocial portion of the study were already receiving psychotherapy on their own.

4. Q. What psychosocial interventions did participants receive?

Researchers randomly assigned participants to receive either a short-term collaborative care intervention or one of three longer-term intensive therapies that have been shown to help stabilize bipolar symptoms—cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), or family-focused treatment (FFT). Collaborative care was considered the “control” intervention, meaning that the outcomes of this therapy were used as a baseline by which to compare the other three intensive therapies. All of these therapies focused on education about the illness, relapse prevention planning, and bipolar illness management interventions, and all but collaborative care consisted of up to 30, 50-minute sessions that took place over nine months.

Collaborative care, which consisted of three, 50-minute sessions over six weeks, provided participants with a workbook, an educational videotape and other information that aimed to help them understand and manage the illness, maintain adherence to medications, and develop a treatment contract geared toward preventing bipolar episodes.

In the CBT intervention group, participants received education about the illness. They learned to challenge negative thoughts or beliefs about bipolar disorder or its associated stressful life circumstances, developed schedules to stay active, and developed strategies to detect and cope with mood swings.

The focus of IPSRT was on attaining and maintaining regular social rhythms (daily routines and sleep/wake cycles) and the relationship of daily activities to mood and levels of social stimulation. IPSRT therapists encouraged participants to keep track of their daily routines (e.g., when they went to sleep, when they woke up, etc.) while working toward establishing stable social rhythms. Patients also worked to resolve key interpersonal problems related to grief, role transitions, interpersonal disputes, or interpersonal skill deficits.

In FFT, participants and their relatives (e.g., spouses and parents) were taught an understanding of bipolar illness, its course, treatment and management. Family members were taught how to recognize early warning signs that might predict an oncoming depressive or manic episode in the person with bipolar illness, and strategies to intervene when these warning signs occurred. Treatment included enhancing communication between the participants and their family members to improve the quality of family interactions, and problem-solving to manage conflicts related to the illness.

5. Q. What do the results from the STEP-BD psychosocial treatment trial tell us about the treatment of bipolar disorder?

The outcome measures that were used to evaluate success of the treatments were “time to recovery” (e.g., how quickly did people get well) and the total amount of time during the study year that participants remained “well” (measured by the probability of being well during any given month). To be considered “well” in the study, participants had to have no more than two symptoms of mild or moderate mania or depression.

Of the 293 STEP-BD participants in the psychosocial treatment study, 59 percent recovered from their depression; 41 percent either did not recover or left the study early.

Over the course of the study year, participants in the intensive psychotherapies (FFT, IPSRT, CBT) had a more successful recovery rate (64 percent) compared to the individuals in the collaborative care group (52 percent). Also, participants in the intensive psychotherapies who recovered did so faster (on average, after about 113 days) than those in the collaborative care group (after about 146 days). Furthermore, the participants in the intensive psychotherapies were one and a half times more likely to remain well during any given month of the study year than those in the collaborative care group.

The study also showed that in each of the four psychosocial treatment groups, participants who were also enrolled in the randomized medication portion of the trial got well faster than those who were not, even though all patients were receiving some type of medication. In addition, recovery time was faster in all four groups for those participants who had family supports available.

Differences among the three intensive psychosocial interventions were not statistically significant, but they are worth noting. Over the yearlong study, 77 percent of participants in the FFT recovered, compared to 65 percent of participants in IPSRT and 60 percent in CBT.

6. Q. What do the results mean for people with bipolar depression and the doctors who provide care for them?

This one-year study showed that, in conjunction with adequate mood stabilizing medications, intensive psychotherapy is more effective in helping people recover from a depressive episode, and stay well over a one-year period, than a brief collaborative care treatment. All three types of intensive psychosocial treatments had comparable benefits.

Overall, psychotherapy appears to be a vital part of the effort to stabilize episodes of depression in bipolar illness. These findings should help clinicians plan treatments for individuals recovering from an episode of bipolar depression.

Postpartum Depression is an illness usually associated with women, but it may come as a surprise to learn that it can also affect men. Studies have shown that one in ten new fathers will experience some of the symptoms of Paternal postpartum depression within three to six months of their baby being born, but their struggles are more likely to go unrecognised than those of their partner.

As with female Postpartum Depression, there is no single cause for why some men develop Paternal Postpartum Depression and not others, although there are groups of men who have been shown to be more likely to suffer from it. research by the UK’s National Childbirth Trust showed that men who had a strained relationship with their partner throughout the pregnancy had an increased risk, along with younger fathers and men who were struggling financially. Men were also more likely to develop it if their partner had Postpartum Depression too.

The symptoms of Paternal Postpartum Depression are very similar to those experienced by women and include:

Feeling very low and despairing
Feeling guilty, irritable or angry
Being unable to sleep, waking early or having nightmares
Having difficulty concentrating or making decisions
Worrying excessively about the baby’s health and wellbeing
Feeling like a failure or feeling inadequate
Comfort eating or not eating at all
Physical symptoms such as headaches
Having thoughts about harming yourself or the baby
However there are symptoms which appear specific to men and include:

A sense of being excluded from the relationship between the mother and baby
Conflict between how you think you should be and how you actually are
Suffering panic attacks or extreme anxiety
Socialising less and avoiding friends
Lack of interest in sex
Not doing well at work
Acting impulsively
Becoming violent
It can be difficult for men to recognise that they are suffering from Paternal Postpartum Depression as there isn’t the same focus and attention given to male postpartum mental health, also it can be hard to identify it as being more than the usual stress, upheaval and challenge a new baby brings. Research has shown that men often don’t acknowledge feelings of sadness, hopelessness or despair, so depression can often be missed by trained mental health professionals. We live in a society that adheres to the cultural myth that men should be stoic and tough and it can be difficult to change a lifetime of conditioning. Women are more likely to talk about their Postpartum Depression, but men are more likely to employ negative coping mechanisms such as drinking excessive amounts of alcohol and working too much, withdrawing into themselves and reacting with anger.

Getting Help for Paternal Postpartum Depression
If you are a man who thinks you may be suffering from Paternal Postpartum Depression it’s important not to ignore it, as left untreated it could get worse or damage your marriage, career or relationship with the baby. There is so much help available and lots of different treatments you could try and the first step is to talk to someone about how you are feeling. It can be difficult to open up, but it’s important to remember that mental health issues are just the same as physical health problems and there is no shame in asking for help. It doesn’t make you less of a man or father to admit your difficulties and Paternal Postpartum Depression is an illness, not a personal weakness. It can help to think of it as being the same as a broken leg; you wouldn’t walk around on it without seeking treatment and mental health is no different.

The first stage is to be honest with yourself about how you feel. There is a short online assessment you could take if you think you may have Paternal Postpartum Depression here although this is to be used as a general guideline and isn’t a substitute for a medical diagnosis. Your doctor is the best person to talk to initially as they can recommend various types of treatment. The options available include:

Counselling
Medication such as anti-depressants
peer support groups
Cognitive Behavioural Therapy (CBT)
It’s important to also reach out to friends, family and co-workers for support too and don’t try to deal with the feelings alone. You could also see if there are any local Dad’s groups or family support agencies who could offer advice. Self-help options can be used alongside any medical treatments such as exercise and making time for interests and hobbies, even if it is only for an hour here and there. There is also a vast amount of support online if it is easier to remain anonymous such as support forums where you can chat with other Dads, plus there are numerous websites offering advice and coping skills. You could also try telephone helplines if it is easier to access support over the phone. If your partner is also suffering from Postpartum Depression you may both need to seek treatment and support at the same time or you could try family therapy.

According to research, the traumatic events like car accident, disasters are time limited. If some of the people experience chronic trauma, the behaviour and coping mechanism of such cases becomes severely impaired. The existing diagnosis of PTSD does not include the severe psychological which happens due to repeated or chronic prolonged trauma. Thee are many additional symptoms such as the way people adapt to stressful events changes permanently.

According to the research professors from Harvard University, there is a need to create new diagnosis for Complex PTSD to understand the real effects of long term and repeated trauma. The Complex PTSD symptoms got another name called Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Developmental Trauma Disorder (DTD) are also present in some of the cases specially children who experience chronic trauma.

What is Complex post-traumatic stress disorder?

The complex trauma which is often used as a separate term for CPTSD, is a result of repetitive and prolonged trauma such as child abuse, intimate partner violence, caregiver abandonment, etc. Few other examples are prisoners of war, concentration camp survivors, captivity or entrapment situations can lead to C-PTSD-like symptoms, It includes long feeling of helplessness and deformation of sense of self.

Although there has been some research done and argues by research community, this illness has not been included in American Psychiatric Association’s DSM 5 as well as in World Health Organization’s ICD 10. There has been a proposition to put it in ICD 18 in the year 2018.

The major differences between PTSD and C-PTSD includes captivity, psychological fragmentation, sense of safety, trust, and self-worth are lost, higher tendency to be revictimized. The most important difference is the loss of coherent sense of self.

What additional symptoms in Complex PTSD?

Following are some of the additional symptoms on top of PTSD which patients of C-PTSD may experience:
1. Emotional Regulation – like persistent sadness, suicidal thoughts, explosive anger, inhibited anger, etc.
2. Consciousness – They tend to forget traumatic events, reliving traumatic events, etc.
3. Self-Perception – This is the top differentiator. It will involve person feeling helpless, guilt, stigma, and a sense of being completely different.
4. Relations with Others is suffered – isolation, distrust, etc.
5. Loss of faith
6. Continued sense of hopelessness and despair

Treatment for Complex PTSD

The Standard evidence-based treatments is very effective for PTSD. For treating Complex PTSD the interpersonal difficulties and specific symptoms are required to be addresses. Recovery from CPTSD requires restoration of control and power for the traumatized person. Here the survivors needs to be empowered by healing relationships. They need strong feeling of safety, remembrance, mourning and everyday life.

ADHD as we know affects a child ability to socialise and interact with anyone. It becomes difficult for the child to make friends. They need help in making and keeping up friends. Parents and support group can create a huge difference by just supervising from distance. They do not have to get on your legs to make this happen and it can be done just by guidance.

Different ways to help ADHD kids make friends

See the tips below to find how you can coach and guide the ADHD child in social interaction and friends making exercise.

1. Know the core of the problem – You need to observe the situation before thinking about any solution. Children with ADHD often commit social behaviour mistakes because they do not know how they are looked upon by their peers. Discuss with them what went wrong and why all of this is happening. Do not provide negative feedback since it will affect his/her self-esteem.

2. Watch your child carefully – The ADHD kids tend to pick fights and verbal arguments with other kids. See what and where they are and closely monitor them. You need to intervene if things are going out of control for your kid.

3. Missing Cues, Lacking Skills – Children with ADHD tend to miss out many things in a friendship. Making and keeping friends needs skills like talking, listening, sharing, being empathetic, etc. In ADHD children, these skill do not come naturally. hence they struggle a lot in this area. This further causes kids to lose self-confidence.

4. Talking to your child’s teacher can also help. The teacher can pair up your child with some child who is more accommodating and accepting. The fiends can be from the same hobby set as well.

5. You can also consider counselling as well. Find out some good Parenting Coach, who can give practical tips on how to help your child interact with others, etc. It can also help the ADHD child build communication skills, and become resilient.

OCD – Obsessive Compulsive Disorder has many manifests which ranges from hypersensitivity which is very common to other behaviour like hyper-responsibility, lying and honesty. The inflated sense of responsibility, and honesty becomes too much to handle and often leads the person to suffer even more.

Hyper-Responsibility and OCD

The inflated sense of responsibility makes the person believe that they are controlling the things which are happening in the world, although they have very little control on their surroundings. There could be many ways in which the hyper-responsibility starts showing its effects. In some cases it shows in terms of the relations to other’s feelings. The person thinks that they are responsible for everyone else’s happiness, and all the times neglects their own feeling. Sometimes, people think that their presence can hurt others, so they isolate themselves from their friends and peers. Another symptoms of responsibility going out of control is people start giving charity and that too an exorbitant amount. All the mails are generally answered by checks and stop saving any money for themselves. They think the world can be saved by their charity.

The below serenity prayer says it all for the inflating sense of responsibility among OCD sufferers:

God grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

Lying and OCD

Another manifest of OCD is lying and often to hide the Obsessive nature about many things. Like one of the kid always lied about his hunger and appetite, making excuses of being tired, etc. The real reason was OCD which made him think that there are finger prints all over the walls and places. These people even though diagnosed with OCD, always lies and say, they are fine, although deep inside they have some thought of obsessive nature. The children lie about taking medicines, all the things which are related to disease and its cure can be lied for. It can be fear of being found out, the fear of what others will think, OCD sufferers lie a lot and it is one of the major manifest of the symptoms.

Honesty and OCD

The above manifest of OCD on Lying has another dimension as well in the form of Honesty. Many of the OCD sufferers has a honesty issues as part of their disorder. They are so afraid of lying that daily they review their entire day within their minds to ensure all what they said was true or not. They many a times accept all the wrongdoing as well as things which they do not do, thinking they might have done it accidentally. Their sense of honesty comes along with hyper-responsibility to keep their loved ones and the world, of course, safe and protected. They have a heightened sense of morality as well.

OCD or obsessive-compulsive disorder has some traditional symptoms which assumes that the patient is aware about the obsessions or compulsions are excessive and they are more than the normal range of feelings. It is often present in the category where the person suffering knows about the condition he is in., i.e. Neuroses. There are some points of contention though. The patients of OCD displays varying degree of insight into their condition. DSM-IV (American Psychiatric Association, 1994) has some mention to this where it is stated that there are cases of people “with poor insight” who “for most of the time” while experiencing an OCD episode do not recognise about their compulsion being excessive or unreasonable. ICD-10 (World Health Organisation, 1992) has no mention of such obsessional symptoms in the presence of schizophrenia.

There are many cases where person suffering from OCD is also diagnosed with some form of borderline Psychosis. Here the OCD is present along with out of touch with reality behaviour. The person suffering is not fully aware about their reactions/behaviour and actions being unreasonable or non-realistic. Psychosis makes anyone think about schizophrenia, although the doctor never mentioned this name. But psychosis in itself is a big symptom of schizophrenia, making things tougher for people who are less aware. The connection of OCD here with psychosis can be described in one line as OCD with poor insight.

People with OCD with Poor Insight

Most of the time people with OCD knows that they are suffering from some kind of obsession which is not normal and there is certain amount of hyper criticality in their behaviour. They are aware that if they tap a wall for 5 times is not going to change anything, but they still do it. They although could not control it, but they are aware about it.

On the contrary if there is OCD with poor insight, such people do not clearly believe that they are irrational or illogical in any way. They think their thoughts and behaviours are not unreasonable, and consider the obsessions and compulsions as normal and stay safe behaviour. The important inclusion in DSM5 says it all. As per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, OCD should be seen with good or fair insight, poor insight, or delusional beliefs.

Why it is important to differentiate OCD with Psychotic Disorders?

The answer to this question lies in the fact that the treatment of Psychotic disorder has some drugs and therapies which enhances the symptoms of OCD. They tend to induce or exacerbate OCD. There are many side effects as well both firm physical and mental aspects.

There is a lot of work for caregivers here to find the comorbid existence of OCD with Psychosis due to obvious readons like the presence of Depression with ADHD. Do not jump to conclusions and specially think about the treatment you think would be suitable for the comorbid conditions. The treatment options of one condition can adversely affect the other condition.

Anxiety is a fearful feeling that seems to get a hold of you and not let go.

It can drive you to act in a demanding or irrational way as you attempt to get relief from the fear. Or it can narrow your world as you reduce your exposure to situations that stimulate the fear.

The emotional side of anxiety can be felt as:

fear,

apprehension,

tension,

agitation,

angst,

stress,

uneasiness,

worry,

nervousness,

a sense of impending doom,

trepidation,

foreboding,

panic, or

being trapped, controlled, or overwhelmed.

Where your anxiety falls on this list of emotion descriptions may be determined by how intense the anxiety is at any given time. (For example, panic is more intense than worry.)

What anxiety feels like physically?

The physical side of anxiety can also be felt at different intensities, from an uneasy jittery physical feeling that accompanies worry, to full bore panic that feels like you are dying.

In fact, panic sends many people to emergency rooms because it can mimic the symptoms of a heart attack.

When anxiety hits its most intense form it is often called a panic attack. (Some call it an anxiety attack, but I think that panic attack is a better label. I see anxiety as less intense than a panic attack.)

A panic attack is very intense for a time—at least 10 minutes—but then usually subsides within an hour. After the panic feeling is reduced, an anxious feeling can remain, but the severity of physical symptoms is not as great as during the panic attack.

Physical symptoms of anxiety can include:

muscular tension, aches, and pains,

headaches,

upset stomach,

gastrointestinal problems (diarrhea, constipation, gas),

loss of appetite or increased appetite,

sweating,

trembling or shaking,

dry mouth,

feeling hot or cold,

hyper energy or low energy,

a lethargic worn-out feeling,

weakness in legs,

sleep disturbance (difficulty getting to sleep or staying asleep),

inability to relax,

brain fog or difficulty concentrating,

hypersensitivity to noise or touch, or

a closed down feeling in throat.

Physical symptoms of a panic attack can include any of the above plus:

chest pain,

increased heart rate,

shortness of breath,

extreme nausea,

extreme shift in body temperature, or

feeling faint or light-headed.

My own experience

I have experienced two panic attacks myself. They definitely are no fun.

Panic attacks are scary multiplied: they are caused by something scary and they are scary.

My first panic attack lasted about a half hour. It was spurred by my receipt of a threatening email from an ex-boyfriend. The panic reduced when I called someone to help me deal with the situation and I felt more secure.

The second panic attack occurred about a week later when I received another email in which his threats escalated. That attack lasted for about an hour. During that attack, I laid down on the floor because I was worried that I might pass out and I figured if I passed out on the floor at least I wouldn’t fall and hurt myself.

After the second attack, I took myself to a hypnotherapist friend. She fixed me up and I never had another panic attack.

I think that my personal experiences with anxiety and panic, combined with my professional education and experience as a counselor, give me an insight into anxiety that is more complete than most.

I know that my clients are often relieved to discover that I have experienced panic first hand and so have an understanding of what they have been through.

“Louise often feels like part of her is “acting.” At the same time, “there is another part ‘inside’ that is not connecting with the me that is talking to you,” she says. When the depersonalization is at its most intense, she feels like she just doesn’t exist. These experiences leave her confused about who she really is, and quite often, she feels like an “actress” or simply, “a fake.”

The majority of the clients I treat have been exposed to repeated traumatic episodes and threats during childhood. For many of these men and women their heinous histories of emotional, psychological and sexual abuse at the hands of trusted caregivers, have led to their suffering from complex PTSD. C-PTSD is more complicated than simple PTSD as it pertains to chronic assaults on one’s personal integrity and sense of safety, as opposed to a single acute traumatic episode. This chronic tyranny of abuse results in a constellation of symptoms, which impact personality structure and development.

The symptom clusters for C-PTSD are:

Alterations in Regulation of Affect and Impulses

Changes in Relationship with others

Somatic Symptoms

Changes in Meaning

Changes in the perception of Self

Changes in Attention and Consciousness

When one is repeatedly traumatized in early childhood, the development of a cohesive and coherent personality structure is hindered. Fragmentation of the personality occurs because the capacity to integrate what is happening to the self is insufficient. The survival mechanism of dissociation kicks in to protect the central organizing ego from breaking from reality and disintegrating into psychosis. Hence, fragmented dissociated parts of the personality carry the traumatic experience and memory, while other dissociated parts function in daily life. Consequentially, profound symptoms of depersonalization and dissociation linked to c-ptsd manifest. (Herman JL. Trauma and Recovery. New York: BasicBooks; 1997)

Dissociative disorders are conditions that involve disruptions or breakdowns of memory, awareness, identity or perception. In the context of severe chronic abuse the reliance on disassociation is adaptive as it succeeds in reducing unbearable distress, and warding off the threat of psychological annihilation. The dissociative disorders a survivor of chronic trauma presents with vary and are inclusive of dissociative identity disorder (formerly multiple personality disorder), dissociative amnesia, Dissociative fugue, and depersonalization disorder. Identify confusion is also deemed a by-product of dissociation and is linked to fugue states when the traumatized person loses memory of their past and concomitantly, a tangible sense of their personal identity. (Onno Van der Hart, Ellert R.S. Nijenhuis, Kathy Steele Dissociation: An Insufficiently Recognized Major Feature of Complex PTSD, Journal of Traumatic Stress, 2005, 18(5))

The treatment process for those afflicted with c-ptsd and attendant dissociative disorders is extensive and comprehensive. Depending on the severity of the repetitious traumas, even in progressed stages of recovery a client may find himself grappling with persistent feelings of detachment and derealization. Given that the brains mediation of psychological functions is dramatically compromised by the impact of chronic trauma, this neurobiological impact may be a strong contributing factor regarding lingering dissociative symptoms in survivors of c-ptsd. When a child’s brain is habitually set to a fear response system so as to survive daily threat, brain cells are killed and the inordinate production of stress hormones interferes with returning to a state of homeostasis. Turning to dissociative states to relieve the pain of hyperarousal, further exacerbates the effective use of one’s executive functions, such as emotional regulation and socialization. Accordingly, neuroimaging findings reveal that cortical processing of emotional material is reduced in those presenting with c-ptsd and an increase in amygdala activity, where anxiety and fear responses persists.

In spite of the harrowing repercussions of prolonged traumatic abuse and neglect, those suffering from c-ptsd and dissociative disorders profit from working through overwhelming material with a caring seasoned professional. Treating the sequelae of complex trauma means establishing stabilization, resolving traumatic memory and achieving personality (re)integration and rehabilitation. Integrating and reclaiming dissociated and disowned aspects of the personality is largely dependent on constructing a cohesive narrative which allows for the assimilation of emotional, cognitive, and physiological realities. And finally when fight/flight responses diminish and an enhanced sense of hope and love for self and others results from years of courageous pain staking hard work, the survivor reaps the rewards of this capricious and harrowing journey; one’s True Self.

Parental alienation is a family dynamic in which one parent engages in many of the 17 primary parental alienation strategies, behaviors likely to foster a child’s unjustified rejection of the other parent. Not all children are susceptible to this form of emotional manipulation, but some are.

When successful, the PA strategies can result in a child claiming to hate and fear a parent who has done nothing to warrant the child’s vitriol, fear, and hostile rejection. Over the past ten years I have conducted a number of research studies on adults who were exposed to PA strategies when they were children. In each study I and my colleagues have found a statistically significant association between exposure to parental alienation in childhood and depression in adulthood.

These findings have been replicated in studies in New York, Texas, US national samples, and in Italy. The findings have been replicated with various depression inventories, and in different age groups. Even high school students will report higher depression when exposed to PA strategies. This association can be understood in light of attachment theory in that the child exposed to PA is being forced to forgo a relationship with an attachment figure and to deny that the loss the relationship has any meaning. The child is denied the opportunity to make meaning of the loss, which is a known risk factor for depression. In one of my studies, a respondent reported that when he was a young boy he came home from school one day and found an unknown man in his living room. His mother announced that this was his new daddy since the old daddy was a bad man.

For the next forty years the boy was not allowed to talk about his father, ask what happened to him, or even refer to him as “Daddy.” Unable to make sense of what happened and forbidden to process the loss, this young boy grew up to experience a multitude of problems as an adult, including depression. Another respondent in that same study told how her father would come to visit every Sunday but she was not allowed to open the door to greet him. In fact, she was forced to stand inside the house yelling at her father through the door to go away and never come back. When the father stopped trying to spend time with her, she was devastated and shared with me that many days – even years later – she felt so sad she couldn’t get out of bed.

What I have learned from stories like these as well as from my statistical studies is that parental alienation is a form of emotional abuse of children and it is, therefore, associated with may negative outcomes for children, including but certainly not limited to depression. Adults who had his experience as children should become educated about parental alienation in order to have a framework for understanding what happened to them.

Likewise, mental health professionals working with such adults should be informed about the phenomenon of parental alienation so that they can be as helpful as possible to this vulnerable population.